Department of Commerce & Insurance»Securities Division [Complaint Form]

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INVESTOR COMPLAINT FORM

Division Contact Information:
Department of Commerce & Insurance
Securities Division
500 James Robertson Parkway
Suite 680
Nashville, Tennessee 37243-0585
Phone: 615-741-5900 or 1-800-863-9117

Click here to find out what happens after your file your complaint.
Click here if you would like to download the complaint form instead of filling it out online.
NOTE: BOXES WITH AN ASTERISK * BESIDE THEM ARE REQUIRED FIELDS

ENTER YOUR CONTACT INFORMATION

*Full Name <<Required Field

*Street <<Required Field

*City <<Required Field

*State <<Required Field *Zip <<Required Field

*Home Phone (XXX-XXX-XXXX) <<Required Field<<XXX-XXX-XXXX
Email (e.g. "abc@site.com")

Work Phone Cell Phone

Best Time To Contact You - Choose One Preferred Contact Type - Choose One

WHOM IS YOUR COMPLAINT AGAINST?

*Name of Person
(Your Complaint is Against) <<Required Field Title

*Name of Company
(Your Complaint is Against) <<Required Field

Company's or Individual's Address

City State Zip Code

Company Phone Company Website

INVESTMENT PRODUCT

Check all that apply.

Stock Bond Mutual Fund Promissory Note Oil & Gas Interest Partnership Unit

Options/Warrants Viaticals Other (If other, Please list here)

Date Invested Amount Invested

Number of Shares/Units Price per Share/Unit

INVESTMENT INFORMATION

Did you receive a prospectus or sales literature before you invested? Yes No

Did you sign a contract to make the investment? Yes No

Please describe how you first learned about this investment opportunity

What specific information were you given that caused you to invest?

Were any statements of fact made before your investment that you now believe were false? Yes No

If so, please describe

Have you learned any important facts since your investment that were not disclosed to you before your investment? Would these facts have changed your decision to invest, had you known those about them in advance? Yes No

If you answered yes to this question, please describe

Did the person who sold you this investment ask you any questions about your financial condition, investment objectives, investment experience or risk tolerance? Yes No

How was the money you invested to be used?

What representations were made about the risk involved in the investment?

COMPLAINT DETAIL

Describe your complaint in detail. Include the names of all persons who were involved in the sale of this investment, include the dates of all persons who were involved in the sale of this investment, include the dates of all conversations and meetings and describe the representations that were made and who made them. Attach copies of all documents related to the investment and the front and back sides of any checks used to purchase the investment. Please use additional paper if needed. (You would need to fill out and print this form and mail it in with your information).

Complaint Detail Describe Here

FINAL STEP

Are you willing to be a witness if proceedings are initiated by the Securities Division? Yes No

The information I have stated in this complaint is true and accurate to the best of my knowledge.

Please type in your name here. Please be advised that a you agree that this digital signature represents your truthful acknowledgment and is a legal signature.

*Signature <<Required Field
*Date (mm/dd/yyyy) <<Required Field<<mm/dd/yyyy

What Happens Next?